Summary WestJet flight 107 (WJA107), a Boeing 737-200 aircraft, was on a scheduled flight from London, Ontario, to Winnipeg, Manitoba. The flight was cleared for take-off from Runway 33 on a London One standard instrument departure, requiring a climb on runway heading to 4000feet above sea level (asl). The tower controller advised that there was visual flight rules (VFR) traffic approximately 8nautical miles (nm) to the northwest at an altitude of 3500feetasl. WJA107 took off at approximately 1433 eastern daylight time and contacted the Toronto area control centre (ACC); again, WJA107 was advised of VFR traffic. WJA107 then received a traffic advisory on the traffic alert and collision avoidance system, followed by a resolution advisory to monitor vertical speed. The aircraft was levelled at 3000feetasl and, shortly thereafter, the ACC controller advised WJA107 to maintain 3000feet. WJA107 had visual contact with the traffic, a Cessna172 aircraft, as the two aircraft passed. Radar data indicate that at 1434:53 the two aircraft flew within 0.6nm laterally and 500feet vertically of each other. Ce rapport est galement disponible en franais. Other Factual Information The visual flight rules (VFR) aircraft involved was a Cessna172, registration C-GFEJ, on a training flight with an instructor and student on board. With authorization from the London control tower, the Cessna was conducting a simulated instrument flight rules (IFR) approach to Runway15, opposite to the active runway, Runway33. The Cessna crossed the London non-directional beacon (NDB) outbound for the approach at 1427:01 eastern daylight time.1 At 1431:24, the tower controller advised the Cessna that a Boeing737 would be departing Runway33 shortly. The tower controller requested that the Cessna pilot maintain the minimum approach speed and avoid cutting the corner on the turn inbound to the airport. This would delay the turn inbound in an effort to increase spacing with WJA107 (see AppendixA). At 1431:51, the tower controller advised WJA107 of a Cessna172, "TCAS2 traffic," 8miles to the northwest at 3500feet above sea level (asl).3 The crew of WJA107 acknowledged the information. On this model of Boeing737, TCAS information is not displayed to the crew until after the aircraft is airborne. At the time this traffic information was provided to WJA107, the Cessna was on a procedure turn inbound for the instrument landing system approach to Runway15. At 1432:27, WJA107 was cleared for take-off on Runway33. The standard instrument departure called for a climb on runway heading to 4000feet, with a note to expect radar vectors. At this time, the Cessna was approximately 8nm northwest of the airport at 3500feet, heading toward the inbound track for Runway15. The tower controller did not advise WJA107or the area control centre (ACC) controller that the Cessna was conducting an approach to Runway15. After WJA107departed, the tower controller attempted to provide further spacing between the two aircraft by instructing the Cessna to continue through the final approach course rather than turn inbound. At 1433:43, WJA107 contacted the ACC controller to report leaving 1700feet for 4000feet. In the climb, the aircraft passed through intermittent cloud conditions. The ACC controller radar identified WJA107, issued a clearance to 11000feet, and cleared the aircraft to proceed directly to the APNEL intersection. The direct track to APNEL required a right turn of approximately 20degrees. The ACC controller did not advise the tower controller of the route change, nor was this required. At 1434:08, the ACC controller, who had spotted the VFR traffic on his radar display, advised WJA107 of traffic 3miles directly ahead at 3500feet. The crew of WJA107 saw the traffic on the TCAS display, and shortly thereafter received a traffic advisory, followed quickly by a resolution advisory (RA) to monitor vertical speed. The crew reported the RAto the ACCand levelled the aircraft at 3000feet. A few seconds later, the ACC controller advised WJA107 to level at 3000feet. WJA107 was flying through cloud tops and was at times in cloud. Because of the potential conflict with the Cessna, WJA107 continued the right turn beyond the heading to the APNEL intersection. The crew saw the Cessna traffic to their left, 500feet above them and in close proximity. After receiving a clear-of-conflict on the TCAS display, WJA107continued the climb on course. At 1434:15, in an effort to ensure that the Cessna would clear WJA107's initial departure path, the tower controller instructed the Cessna to turn left to a heading of 090degrees. The tower controller was unaware that WJA107 had been instructed to make a right turn on course, and the heading of 090degrees actually increased the risk of collision by increasing the time the two aircraft were in conflict. At 1434:26, the ACC controller learned that the Cessna pilot had reported WJA107 in sight and that the Cessna had remained at 3500feet throughout the simulated approach. The two aircraft passed with 500feet vertical spacing and 0.6nm lateral spacing, on a converging course, 4nm north of London International Airport. WJA107 was still in the London ClassD control zone at 3000feet, and the Cessna was in ClassE airspace at 3500feet. There is a requirement for air traffic control (ATC) to provide traffic information, workload permitting, but not conflict resolution between IFRand VFRtraffic operating entirely in ClassE airspace. In this incident, both aircraft had authority to operate in the control zone. The tower controller was controlling seven aircraft in the 10-minute period before the incident, including the Cessna on the reciprocal approach, WJA107 departing Runway33, and a helicopter flying left-hand circuits to the button of Runway09. The workload was considered moderate with some complexity. At the time of the occurrence, the staffing level in the London tower was in accordance with local procedures. The airport and ground positions were operational, with three controllers available for duty. The London tower is equipped with a radar display to assist the controller in maintaining situational awareness of aircraft operating in the vicinity of the airport. The control zone at the London International Airport includes the airspace within a radius of 5nm from the surface to 3000feet, and is designated as ClassD airspace. The Canadian Aviation Regulations (CARs) state that when air traffic control services are provided to aircraft flying in ClassD airspace, they shall include traffic information and separation between IFR aircraft. The Aeronautical Information Publication expands on the procedures to be employed for aircraft flying in ClassD airspace, including the following: a VFR aircraft must establish two-way radio communication with the appropriate ATC agency prior to entering ClassD airspace, ATS separation is provided only to IFR aircraft; aircraft will be provided with traffic information, and conflict resolution will be provided between IFR and VFR aircraft, equipment and workload permitting. The airspace surrounding the London control zone below 12500feet is designated ClassE airspace in which ATC provides separation between IFR aircraft. There are no special communication requirements for VFRaircraft flying in this airspace, and the aircraft are not subject to air traffic control, except that ATCwill provide traffic information, workload permitting. The flight path for the instrument approaches to the London International Airport are largely contained within ClassE airspace, except for the final approach portion between the NDBs and the threshold of the runway. The weather-related requirements for VFR flight in controlled airspace (ClassD andE) are as follows: the aircraft is to be flown clear of cloud and within sight of the ground, visibility must be not less than 3 statute miles (sm), and the distance from cloud must be at least 1 sm horizontally and 500 feet vertically. The London International Airport is 912feet asl. The weather at 1400 was as follows: wind 310True at 10knots, visibility 15sm, cloud ceiling 1800feet above ground level, altimeter 2989. At 1500, the weather was as follows: scattered cloud at 1500feet above ground level, thin broken cloud at 20000feet, visibility 15sm, altimeter 2989. The weather was improving, with fewer clouds and no ceiling. The Cessna pilot could maintain VFRbut, at times, could not see the airport. NAV CANADA management at the London International Airport has provided specific guidance in the London Control Tower Unit Operations Manual (UOM) to better manage VFR aircraft operations in ClassD and Eairspace in the vicinity of the airport. Specifically, the UOM states: With respect to reciprocal operations, Section4.15.6.2 of the London UOM states the following: The tower controller did not adhere to the above procedures. To minimize the impact on other air traffic using the active runway, an informal but routine practice has been used at the London Airport to allow helicopters conducting training to fly circuits to the threshold of an out-of-wind runway. There are no written procedures for helicopter pilots or tower control staff to follow: headings, altitudes, traffic information, contingencies, and simultaneous operations with aircraft using the active runway. The access to Taxiway B, leading to the threshold of Runway09, is an uncontrolled taxiway. There are no procedures in place to ensure that other aircraft or vehicles do not infringe on the landing areas being used by helicopters. At the time WJA107 was cleared for take-off, a helicopter was on the ground on the threshold of Runway09 with a valid touch-and-go clearance issued by the tower controller. The helicopter departed at the same time as WJA107. The tower controller did not provide traffic information to either aircraft about the operation of the other. Air Traffic Control Manual of Operations (ATC MANOPS), paragraph353.1, allows controllers to "issue take-off or landing clearance to a helicopter provided the operation takes place on the manoeuvring area," that is, a runway or a taxiway. The same paragraph also states, "because of their operational characteristics, it is not always necessary that helicopters adhere to the standard traffic circuit, land or take off on the same runway or follow the flight path used by fixed-wing aircraft." The Air Traffic Services Administration and Management Manual, paragraph211.2, states that managers "shall coordinate the development of unit procedures if helicopter operations are routinely carried out." Section4.8 of the UOM describes helicopter operations at the London International Airport. It states that "arrivals/departures of helicopters will be to/from a runway only." There are no published guidelines or procedures for conducting helicopter circuits to an out-of-wind runway threshold at the same time as fixed-wing operations are being conducted from the active runway. A London tower Operations Bulletin, 03-21issued on 21August2003, titled "Exchange of Traffic Information," instructed controllers not to make reference to TCAS equipment when exchanging traffic information and, instead, to follow directions contained in the ATC MANOPS. The bulletin was scheduled to expire on 21September2003. It was written in response to information provided by NAV CANADA's head office to the London tower manager. The manager of the London tower received management support from staff of NAV CANADA's Eastern Regional Office to review and revise existing procedures and to develop new ones. An ATC specialist from the regional office routinely conducted an analysis of operational unit recordings and provided the London tower manager with observations. In the London tower, there are no supervisory positions established, and the unit operations specialist position had not been staffed on a permanent basis for the previous two years. Proficiency checks and training were being carried out by operational controllers without direct operational oversight.